Changing the Landscape of Adult to Adult Living Donor Liver Transplantation: The Role of the Small for Size Grafts.

Abstract

Liver transplantation (LT) is the optimal treatment of small and oligocentric hepatocelluar carcinoma (HCC) in cirrhotic livers. Hepatic resection (LR) is considered a feasible alternative to LT, either as bridging or as discrete procedure. Patients and Methods: Two-hundred-nineteen patients with HCC surgically treated at our institution between September 1997 and December 2008 were included in this analysis. All LT candidates (n=171) underwent repeatedly performed transarterial chemoembolization (TACE) before transplantation. According to our protocol TACE was performed in intervals of 6 weeks until transplantation. During the same period 64 patients with liver cirrhosis (Child A: n= 61, Child B: n=2) were treated by LR. Results: Of the 171 LT candidates, 110 exceeded the MC. Transplant candidates were significantly younger than patients undergoing LR (59.5; 36-73 versus 67.2; 37-84 yrs; p<0.001). 112 patients were finally transplanted (MC in: 50, MC out: 62). Accordingly, the dropout rate during a median waiting time of 218 (22-756) days was 35%. Five-year survival in all patients undergoing LT was 68% compared to 22% in LR patients p<0.001).If all transplant candidates are included in the Kaplan Meier analysis (intention-to-treat analysis), 5-year survival dropped to 56 %. Even this rate is significantly superior to the survival after LR (p=0.003). Patients meeting the MC have a similar prognosis regardless of the surgical approach (LT versus LR: p=0.541) whereas patients exceeding the MC fare better with LT compared to LR (5-year survival 51 vs. 15%; p=0.003). Patients with AFP >400 nG/ml have a 5-year survival of 49% compared to 11 % in LR patients. This difference is not significant (p=0.130), whereas in patients with AFP <400nG/ml survival was significantly different (p=0.034). Conclusions: Despite a dropout rate of 35% during pre-treatment by repeatedly performed TACE, LT results in superior overall survival compared to LR in the intention-to-treat analysis. A subgroup (intention-to-treat) analysis of patients meeting the MC indicates comparable survival after LT and LR. According to these results LR remains a feasible treatment option in patients with small and oligofocal tumors, in particular in view of graft scarcity.

Challenges and Outcome of Left-lobe Liver Transplants in Adult Living Donor Liver Transplants

“…29 Others have used similar methods for portal flow diversion such as inferior mesenteric vein to the left renal vein shunts or the innovative hemiportocaval shunts (Figure 6), where the right branch of the portal vein (which is free in the left-lobe transplants) is connected to the IVC either directly or using interposition grafts such as recipient portal vein or synthetic grafts. [30][31][32][33][34] However, sometimes the diverted…”

Fifteen millimeters of mercury

“…SAL appears to confer a limited and transient effect on PVP modulation; HPCS effectively modulates PVP, improves graft function, and prevents SFSS but carries a theoretical risk of flow diversion (steal phenomenon) and graft atrophy. Other groups in Europe7 and North America8 have successfully applied HPCS. The same group from Kyoto recently reported 100% survival and complete avoidance of SFSS in 11 patients with small grafts and the construction of HPCS 9.…”